Selective Transvenous Embolization of Dural Arteriovenous Fistulas Involving the Hypoglossal Canal

The hypoglossal canal contains a venous plexus that connects the inferior petrous sinus, condylar vein, jugular vein and paravertebral plexus. The venous plexus is one of the venous drainage routes of the posterior skull base. Only a few cases of dural arteriovenous fistulas (AVFs) involving the hypoglossal canal have been reported. We describe three cases (a 62-year-old female, a 52-year-old male, and an 83-year-old male) of dural AVFs involving the hypoglossal canal. Symptoms were pulse-synchronous bruit in two cases and proptosis/chemosis in one. All dural AVFs were mainly fed by the ipsilateral ascending pharyngeal artery. Two of three dural AVFs involving the hypoglossal canal mainly drained through the anterior condylar confluence into the inferior petrosal sinus retrogradely with antegrade drainage through the lateral condylar vein. The other one drained through the lateral and posterior condylar veins into the suboccipital cavernous sinus. All dural AVFs were completely occluded by selective transvenous embolization without any complications, and the symptoms disappeared within one week in all cases. Dural AVFs involving the hypoglossal canal can be successfully treated by selective transvenous embolization with critical evaluation of venous anatomy in each case.

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Transvenous embolization of a posterior condylar canal fistula causing pulsatile tinnitus

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016280 ◽

2020 ◽

pp. neurintsurg-2020-016280

Author(s):

Waleed Brinjikji ◽

Giuseppe Lanzino ◽

Harry J Cloft

Keyword(s):

Skull Base ◽

Motor Vehicle ◽

Motor Vehicle Accident ◽

Treatment Decision ◽

Occipital Artery ◽

Pulsatile Tinnitus ◽

Transvenous Embolization ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Posterior Condylar

Dural arteriovenous fistulas of the skull base commonly present with pulsatile tinnitus. In our experience, transvenous embolization of dural arteriovenous fistulas of the skull base represents a safe and effective treatment modality due to its precision in treatment of the site of convergence of all feeding arteries and the low risk of ischemic complications. We present a case of an adult patient who presented to our institution with pulsatile tinnitus several months following a motor vehicle accident. Cerebral angiography demonstrated a dural arteriovenous fistula at the junction of the posterior condylar vein and suboccipital venous plexus supplied by branches of the vertebral artery, occipital artery, and ascending pharyngeal artery. In this operative video we demonstrate this technique and provide an in-depth discussion of our treatment decision-making process and the anatomical considerations involved in treating this lesion.

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Dural arteriovenous fistulas of the hypoglossal canal: systematic review on imaging anatomy, clinical findings, and endovascular management

Journal of Neurosurgery ◽

10.3171/2014.10.jns14377 ◽

2015 ◽

Vol 122 (4) ◽

pp. 883-903 ◽

Cited By ~ 35

Author(s):

Björn Spittau ◽

Diego San Millán ◽

Saad El-Sherifi ◽

Claudia Hader ◽

Tejinder Pal Singh ◽

...

Keyword(s):

Cavernous Sinus ◽

Case Reports ◽

Transarterial Embolization ◽

Venous Anatomy ◽

Hypoglossal Canal ◽

Arteriovenous Fistulas ◽

Small Series ◽

Dural Arteriovenous Fistulas ◽

Type 3

Dural arteriovenous fistulas (DAVFs) of the hypoglossal canal (HCDAVFs) are rare and display a complex angiographic anatomy. Hitherto, they have been referred to as various entities (for example, “marginal sinus DAVFs”) solely described in case reports or small series. In this in-depth review of HCDAVF, the authors describe clinical and imaging findings, as well as treatment strategies and subsequent outcomes, based on a systematic literature review supplemented by their own cases (120 cases total). Further, the involved craniocervical venous anatomy with variable venous anastomoses is summarized. Hypoglossal canal DAVFs consist of a fistulous pouch involving the anterior condylar confluence and/or anterior condylar vein with a variable intraosseous component. Three major types of venous drainage are associated with distinct clinical patterns: Type 1, with anterograde drainage (62.5%), mostly presents with pulsatile tinnitus; Type 2, with retrograde drainage to the cavernous sinus and/or orbital veins (23.3%), is associated with ocular symptoms and may mimic cavernous sinus DAVF; and Type 3, with cortical and/or perimedullary drainage (14.2%), presents with either hemorrhage or cervical myelopathy. For Types 1 and 2 HCDAVF, transvenous embolization demonstrates high safety and efficacy (2.9% morbidity, 92.7% total occlusion). Understanding the complex venous anatomy is crucial for planning alternative approaches if standard transjugular access is impossible. Transarterial embolization or surgical disconnection (morbidity 13.3%–16.7%) should be reserved for Type 3 HCDAVFs or lesions with poor venous access. A conservative strategy could be appropriate in Type 1 HCDAVF for which spontaneous regression (5.8%) may be observed.

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Cerebral venous drainage in patients with dural arteriovenous fistulas: correlation with clinical presentation

Journal of Neurosurgery ◽

10.3171/2020.6.jns20922 ◽

2020 ◽

pp. 1-9

Author(s):

João Ferreira de Melo Neto ◽

Eduardo E. Pelinca da Costa ◽

Nilson Pinheiro Junior ◽

André L. Batista ◽

Georges Rodesch ◽

...

Keyword(s):

Alternative Pathway ◽

Venous Drainage ◽

Venous Hypertension ◽

Normal Brain ◽

High Grade ◽

Venous Anatomy ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Group 2 ◽

Group 1

OBJECTIVEDural arteriovenous fistulas (DAVFs) are abnormal, acquired arteriovenous connections within the dural leaflets. Their associated symptoms may be mild or severe and are related to the patient’s venous anatomy. With the hypothesis that the patient’s venous anatomy determines the development of symptoms, the authors aimed to identify which venous anatomy elements are important in the development of major symptoms in patients with a DAVF.METHODSA multicenter study was performed based on the retrospective analysis of cerebral angiographies with systematic assessment of brain drainage pathways (including fistula drainage) in patients over 18 years of age with a single DAVF. The patients were divided into two groups: those with minor (group 1, n = 112) and those with major (group 2, n = 89) symptoms. Group 2 was subdivided into two groups: patients with hemorrhage (group 2a, n = 47) and patients with severe nonhemorrhagic symptoms (group 2b, n = 42).RESULTSThe prevalence of stenosis in DAVF venous drainage and the identification of tiny anastomoses between venous territories were significantly higher in group 2 (32.6% and 19.1%, respectively) compared with group 1 (2.68% and 5.36%, respectively). Stenosis of DAVF venous drainage was significantly more frequent in group 2a than in group 2b (51.1% vs 11.9%, p < 0.001). Group 2b patients had increased prevalence of shared use of the cerebral main drainage pathway (85.0% vs 53.2%, p = 0.002), the absence of an alternative route (45.0% vs 17.0%, p = 0.004), and the presence of contrast stagnation (62.5% vs 29.8%, p = 0.002) compared with group 2a patients. In patients with high-grade fistulas, the group with major symptoms had increased prevalence of a single draining direction (31.3% vs 8.33%, p = 0.003), stenosis in the draining vein (35.0% vs 6.25%, p = 0.000), the absence of an alternative pathway for brain drainage (31.3% vs 12.5%, p = 0.017), and the presence of contrast stagnation (48.8% vs 22.9%, p = 0.004).CONCLUSIONSMajor symptoms were observed when normal brain tissue venous drainage was impaired by competition with DAVF (predominance in group 2b) or when DAVF venous drainage had anatomical characteristics that hindered drainage, with consequent venous hypertension on the venous side of the DAVF (predominance in group 2a). The same findings were observed when comparing two groups of patients with high-grade lesions: those with major versus those with minor symptoms.

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Transvenous Embolization of Dural Arteriovenous Fistulas of the Hypoglossal Canal: Report of Three Cases and Review of the Literature

Interventional Neurology ◽

10.1159/000488500 ◽

2018 ◽

Vol 7 (6) ◽

pp. 315-322

Author(s):

Alejandro Santillan ◽

Justin Schwarz ◽

Athos Patsalides

Keyword(s):

Transvenous Embolization ◽

Endovascular Management ◽

Review Of The Literature ◽

Hypoglossal Canal ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Transvenous Approach

In this article, we report three cases of dural arteriovenous fistulas of the hypoglossal canal treated via transvenous approach. We also perform a review of the literature on the endovascular management of this type of lesions with particular attention to the dangerous extracranial-intracranial anastomoses that can occur at this level.

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Ocular symptoms associated with a dural arteriovenous fistula involving the hypoglossal canal: selective transvenous coil embolization

Journal of Neurosurgery ◽

10.3171/jns.2001.94.4.0630 ◽

2001 ◽

Vol 94 (4) ◽

pp. 630-632 ◽

Cited By ~ 37

Author(s):

Hiro Kiyosue ◽

Shuichi Tanoue ◽

Mika Okahara ◽

Miyuki Mori ◽

Hiromu Mori

Keyword(s):

Coil Embolization ◽

Venous Drainage ◽

Resonance Imaging ◽

Content Type ◽

Hypoglossal Canal ◽

Arteriovenous Fistulas ◽

Ocular Symptoms ◽

Dural Arteriovenous Fistulas ◽

Careful Assessment

✓ The hypoglossal canals are an unusual location for dural arteriovenous fistulas (AVFs) to appear. One previous report of dural AVFs involving the hypoglossal canal has been published. In the present paper, the authors describe a dural AVF within the hypoglossal canal, which presented with ocular symptoms and was successfully treated by selective transvenous embolization. Magnetic resonance imaging and contralateral carotid arteriography were useful for determination of the exact location of the fistulous pouch, which was later packed with coils. Selective transvenous coil embolization with careful assessment of the location and pattern of the venous drainage of the dural AVF is a safe and effective treatment.

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Balloon-backstop technique: Preserving physiologic venous drainage during transvenous coil embolization of sigmoid sinus dural arteriovenous fistulas

The Neuroradiology Journal ◽

10.1177/19714009211042898 ◽

2021 ◽

pp. 197140092110428

Author(s):

Madhavi Duvvuri ◽

Michael T Caton ◽

Kazim Narsinh ◽

Matthew R Amans

Keyword(s):

Arteriovenous Fistula ◽

Coil Embolization ◽

Dural Arteriovenous Fistula ◽

Venous Drainage ◽

Sigmoid Sinus ◽

Transvenous Embolization ◽

Venous Infarction ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Superior Petrosal Sinus

Dural arteriovenous fistulas can lead to catastrophic intracranial hemorrhage if left untreated. Transvenous embolization can cure arteriovenous fistulas, but preserving normal venous structures can be challenging. Inadvertent embolization of a functioning vein can result in catastrophic venous infarction or hemorrhage. Here, we report a case using balloon-assistance to facilitate preservation of the superior petrosal sinus during transvenous embolization of a sigmoid sinus dural arteriovenous fistula.

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Critical Review of Clinical Aspects and Treatment Strategies of Cranial Dural Arteriovenous Malformations

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v22i3.1025 ◽

2018 ◽

Vol 22 (3) ◽

pp. 87-94

Author(s):

Marco Antônio Stefani ◽

Apio Claudio Martins Antunes

Keyword(s):

Treatment Strategies ◽

Venous Drainage ◽

Clinical Aspects ◽

Venous Reflux ◽

Venous Anatomy ◽

Anatomical Features ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Cerebral Venous Drainage ◽

Cortical Venous Reflux

The authors discuss the treatment strategies for dural arteriovenous fistulas, considering anatomical features such as the presence of cortical venous reflux (CVR) and patterns of cerebral venous drainage. Illustrative cases are presented with the different clinical and angiographic features, focusing on patterns of arterial and venous anatomy, normal cerebral venous drainage and the presence of cortical venous reflux. A review of the pathophysiology and current classifications are presented. The treatment strategies are discussed, focusing on the endovascular procedures available. Dural arteriovenous fistulas should be treated considering the significant risks of hemorrhage related to the presence of CVR. Treatment strategies should aim angiographic and clinical cure, achieved with low risk of complications when using a multidisciplinar approach, after carefull understanding of the venous drainage, respecting the anatomy of the lesion and the normal cerebral venous drainage.

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The Angle of the Microguidwire on the Lateral Projection: a Prediction of Cannulation of the Occluded Inferior Petrosal Sinuses for the Transvenous Embolization of Cavernous Sinus Dural Arteriovenous Fistulas

10.21203/rs.3.rs-707075/v1 ◽

2021 ◽

Author(s):

Xianli Lv

Keyword(s):

Internal Jugular Vein ◽

Cavernous Sinus ◽

Jugular Vein ◽

Inferior Petrosal Sinus ◽

Transvenous Embolization ◽

Lateral Projection ◽

Arteriovenous Fistulas ◽

Fluoroscopic Image ◽

Dural Arteriovenous Fistulas ◽

Transvenous Approach

Abstract OBJECTIVE: To describe that the angle of the guidwire on lateral projection under fluoroscopic image is a prediction of cannulation of the occluded inferior petrosal sinus in the transvenous embolization of cavernous sinus dural fistulas.METHODS: From January 2018 through January 2021, 12 consecutive cavernous sinus dural fistulas with ipsilateral inferior petrosal sinus occlusion identified in 12 patients were cured by cannulation of the occluded ipsilateral inferior petrosal sinus. Clinical, radiologic and procedure data of the 12 patients were retrospectively reviewed. The angle of microguidewire between on lateral projection under fluoroscopic image between the inferior petrosal sinus and the internal jugular vein was measured by 180°Protractor(Deli Group Co., LTD, Zhejiang, China). RESULTS: In the 12 patients, access via the occluded ipsilateral inferior petrosal sinus was primarily attempted as the transvenous approach. During the procedure, the angle of microguidwire on lateral projection under fluoroscopic image between the inferior petrosal sinus and the internal jugular vein was 117°±7°, which is very useful to confirm the cannulation of the occluded inferior petrosal sinus. Complete occlusion was achieved in all fistulas, with no procedure-related morbidity or mortality. Postprocedural symptom was improved in all patients. CONCLUSION: Cannulation of an occluded inferior petrosal sinus is possible and reasonable as an initial access attempt for cavernous sinus dural fistulas. The angle of microguidwire on the lateral projection under fluoroscopic image can help to confirm the orifice of the occluded inferior petrosal sinus.

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Dural arteriovenous fistula of the anterior condylar confluence and hypoglossal canal mimicking a jugular foramen tumor

Journal of Neurosurgery ◽

10.3171/jns/2008/109/8/0335 ◽

2008 ◽

Vol 109 (2) ◽

pp. 335-340 ◽

Cited By ~ 15

Author(s):

James K. Liu ◽

Kelly Mahaney ◽

Stanley L. Barnwell ◽

Sean O. McMenomey ◽

Johnny B. Delashaw

Keyword(s):

Nerve Palsy ◽

Hypoglossal Nerve ◽

Transarterial Embolization ◽

Jugular Foramen ◽

Jugular Bulb ◽

Venous Plexus ◽

Hypoglossal Nerve Palsy ◽

Hypoglossal Canal ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas

The anterior condylar confluence (ACC) is located on the external orifice of the canal of the hypoglossal nerve and provides multiple connections with the dural venous sinuses of the posterior fossa, internal jugular vein, and the vertebral venous plexus. Dural arteriovenous fistulas (DAVFs) of the ACC and hypoglossal canal (anterior condylar vein) are extremely rare. The authors present a case involving an ACC DAVF and hypoglossal canal that mimicked a hypervascular jugular bulb tumor. This 53-year-old man presented with right hypoglossal nerve palsy. A right pulsatile tinnitus had resolved several months previously. Magnetic resonance imaging demonstrated an enhancing right-sided jugular foramen lesion involving the hypoglossal canal. Cerebral angiography revealed a hypervascular lesion at the jugular bulb, with early venous drainage into the extracranial vertebral venous plexus. This was thought to represent either a glomus jugulare tumor or a DAVF. The patient underwent preoperative transarterial embolization followed by surgical exploration via a far-lateral transcondylar approach. At surgery, a DAVF was identified draining into the ACC and hypoglossal canal. The fistula was surgically obliterated, and this was confirmed on postoperative angiography. The patient's hypoglossal nerve palsy resolved. Dural arteriovenous fistulas of the ACC and hypoglossal canal are rare lesions that can present with isolated hypoglossal nerve palsies. They should be included in the differential diagnosis of hypervascular jugular bulb lesions. The authors review the anatomy of the ACC and discuss the literature on DAVFs involving the hypoglossal canal.

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Advances in Surgical Approaches to Dural Fistulas

Neurosurgery ◽

10.1227/neu.0000000000000228 ◽

2014 ◽

Vol 74 (suppl_1) ◽

pp. S32-S41 ◽

Cited By ~ 19

Author(s):

Patrick P. Youssef ◽

Albert Jess Schuette ◽

C. Michael Cawley ◽

Daniel L. Barrow

Keyword(s):

Treatment Options ◽

Venous Drainage ◽

Venous Hypertension ◽

Surgical Approaches ◽

Dural Sinus ◽

Intraoperative Angiography ◽

Indocyanine Green Videoangiography ◽

Arteriovenous Fistulas ◽

The Past ◽

Dural Arteriovenous Fistulas

Abstract Dural arteriovenous fistulas are abnormal connections of dural arteries to dural veins or venous sinuses originating from within the dural leaflets. They are usually located near or within the wall of a dural venous sinus that is frequently obstructed or stenosed. The dural fistula sac is contained within the dural leaflets, and drainage can be via a dural sinus or retrograde through cortical veins (leptomeningeal drainage). Dural arteriovenous fistulas can occur at any dural sinus but are found most frequently at the cavernous or transverse sinus. Leptomeningeal venous drainage can lead to venous hypertension and intracranial hemorrhage. The various treatment options include transarterial and transvenous embolization, stereotactic radiosurgery, and open surgery. Although many of the advances in dural arteriovenous fistula treatment have occurred in the endovascular arena, open microsurgical advances in the past decade have primarily been in the tools available to the surgeon. Improvements in microsurgical and skull base approaches have allowed surgeons to approach and obliterate fistulas with little or no retraction of the brain. Image-guided systems have also allowed better localization and more efficient approaches. A better understanding of the need to simply obliterate the venous drainage at the site of the fistula has eliminated the riskier resections of the past. Finally, the use of intraoperative angiography or indocyanine green videoangiography confirms the complete disconnection of fistula while the patient is still on the operating room table, preventing reoperation for residual fistulas.

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